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‘Prognosis’ is a word we commonly link to clinical medicine, describing the likely course of a disease or ailment, as in the phrase "the disease has a poor prognosis." However, the word has a more general application to mean the likely outcome of a situation. The Institute for Work & Health (IWH) is no stranger to prognosis, having conducted research in this field related to injury and work disability prevention. Most notably, it has conducted very high quality research on the factors that accurately predict the duration of work disability, which has been incorporated by the Ontario Workplace Safety & Insurance Board (WSIB) into its reform of return-to-work (RTW) case management service delivery for Ontario workers.

Soft-tissue injuries of the musculoskeletal system are a major cause of work-related disability in the developed economies. For example, in the province of Ontario, approximately 40 per cent of workers’ compensation lost-time claims are attributed to soft-tissue injuries of the low back. In the large majority of disability episodes due to work-related musculoskeletal disorders, the natural course of recovery and return-to-work is uncomplicated. However, a minority of claimants are disabled from working for longer periods of time. Clinicians and disability case managers were aware of these differences in recovery durations, but were generally uncertain about whether it was possible to predict, early in a disability episode, who would have a normal, uncomplicated recovery and who would have a long-duration disability episode.

IWH prognostic research tackles disability durations

This was the context in the late 1990s, when an IWH research team was formed around an interest in improving knowledge of key factors that were prognostic of disability durations in work-related soft-tissue disorders of the back, upper limbs and lower limbs. The research team was aware that the international research literature was dominated by studies of small to moderate sample size, with concerns about the population representativeness of samples. Most of the published research at that time, relying on either administrative data or clinical observations, did not incorporate information provided by disabled workers about their perceptions of their condition and the characteristics of their employment.

The IWH research team drew on information collected by a primary research study of more than 900 Ontario workers who had received wage-replacement benefits for a wide range of work-related soft-tissue injuries of the back, upper limb and/or lower limb. The study subjects participated in five telephone interviews over a one-year period, and provided information on their health status, pain symptoms and history of soft-tissue disorders, as well as their perceptions of their expectations of recovery. The novel analytic method used by the project team carefully identified the factors measured early in the disability episode that predicted the duration of disability.

In a research paper published in 2003, four factors explained 40 per cent of the variance in disability durations: (1) measures of functional status, (2) the worker’s recovery expectations, (3) changes in pain severity over time, and (4) whether the workplace had made an offer of modified work. These four pieces of information were strongly prognostic. For example, 16 weeks following the onset of injury, over 95 per cent of the lowest risk group had returned to work, while only one-third of the highest risk group had returned to work.

WSIB team incorporates findings into service delivery

A few years following the publication of the research paper, the WSIB established an internal project team to develop the elements of a case management program that came to be called the ‘New Service Delivery Model’. The goal of this program reform was to provide enhanced case management services to employers and workers with the objective of reducing the durations of disability for work-related injury and illness. The service delivery reforms were intricate, involving new roles for WSIB staff, enhanced information technology applications and a strengthened emphasis on communication with workers and employers. Under this model, frontline service delivery staff used a consistent and standardized case management approach to identify, assess and co-ordinate eligibility decisions, health-care services and return to work.

One dimension of the internal project team’s work was to review the research literature to identify those factors that, on average, were associated with better return-to-work outcomes. The internal project team came to recognize the importance of the information reported in the IWH study, and have worked over a number of years to implement procedures to collect information from workers and from clinicians that would assist case managers in identifying, early in a disability episode, those claimants who may have longer disability durations.

What has been the impact?

John Mutch, Director, Return to Work at the WSIB, described the focus on prognostic measures during the design of the New Service Delivery Model as ”foundational.” The collection of information on those characteristics of worker health status, workers’ expectations of recovery, and the relationship between the worker and the employer that were associated with favourable and less favourable return-to-work outcomes would inform decisions about case management involvement in individual disability episodes.

Over the past number of years, the collection of relevant prognostic information from health-care providers has been a priority. The ‘Health Professional’s Report’ (Form 8) has been revised to incorporate a numeric pain rating scale. Health-care providers participating in the WSIB’s programs of care are now expected to measure and report patient functional status and pain intensity, using standardized instruments both at initial assessment and at the completion of the care program.

Most recently, WSIB case managers have been provided training in motivational interviewing, a technique with a strong foundation of effectiveness in clinical care settings. In clinical setttings, motivational interviewing is focused on identifying an individual patient’s apprehensions or concerns that are a barrier to their participation in recommended therapy, and coaching the patient to recognize and adjust these concerns. The technique has a promising application in the context of work disability, where a worker’s poor expectations for recovery or concerns about returning to work may be addressed in a supportive interview.

Following the implementation of the New Service Delivery Model over the 2008-2009 period, the WSIB has monitored progress in improved work disability outcomes. For example, the percentage of workers who returned to work within 12 months with no wage loss increased to 92 per cent in 2015 from 85 per cent in 2008. While the share of this improvement that can be attributed to the integration of prognostic information in return-to-work case management decisions and services is uncertain, the program commitment to incorporating evidence-based prognostic information is very clear.